Pre-exposure prophylaxis (PrEP) in an era of stalled HIV prevention: Can it change the game?

Knowledge and perception of HIV pre-exposure prophylaxis among healthcare workers

Introduction: In Brazil, pre-exposure prophylaxis (PrEP) is freely available to individuals at high risk of HIV infection. However, knowledge and perception of PrEP can act as barriers to its access and use. This study evaluated PrEP knowledge and perception among healthcare workers in the Unified Health System in a Brazilian capital. Methods: This cross-sectional study collected data through interviews with healthcare workers from 72 Primary Health Care (PHC) units and 5 Specialized Care (SC) services in Campo Grande, Mato Grosso do Sul. Binomial logistic regression models were used to analyze factors associated with PrEP knowledge and perception. Results: A total of 372 professionals were interviewed. The majority were PHC professionals (93.0%), female (76.1%), aged between 30 and 39 years (41.4%), heterosexual (83.3%), and non-white (51.9%). PrEP knowledge was higher among LGBTQIA + professionals, those with less than one year of healthcare work experience, those with a positive perception of PrEP, and those attending more patients per day. A positive perception of PrEP was significantly higher among professionals who care for people living with HIV and lower among those with limited knowledge about PrEP. Discussion: Identifying factors influencing PrEP access may help develop strategies to improve knowledge and perception, particularly in high-impact areas.

Consistency of Condom Use with Lubricants and Associated Factors Among Men Who Have Sex with Men in Ghana: Evidence from Integrated Bio-Behavioral Surveillance Survey

Several studies conducted worldwide have reported on the effectiveness of consistent condom use with lubricants in preventing HIV transmission and acquisition; however, men who have sex with men (MSM) in Ghana continue to be disproportionately affected by the HIV burden. They are stigmatized, discriminated against, and criminalized, leading to social isolation, reduced access to health care, and inadequate targeted interventions. The dissemination of HIV prevention tools such as condoms and lubricants is also mainly focused on the general population, and this approach overlooks the specific needs and vulnerabilities of MSM. This study aimed to determine the prevalence and associated factors of consistent condom use with lubricants among MSM in Ghana. We analyzed cross-sectional data from the Ghana Men's Study II dataset involving 4095 MSM aged 18 years and above. De-identified data were imported into STATA (College Station, TX, USA, software version 17) for data analysis. Descriptive analysis was performed to describe relevant characteristics of the study population. Multivariable logistic regression analysis was performed for significant variables in bivariate analysis to determine the associated factors of consistent condom use with lubricants. All the statistical analyses were performed at a 95% confidence interval, with significant differences at p < 0.05. The prevalence of consistent condom use with lubricants during penetrative anal sex was highest with male partners (44.9%), followed by female partners (40.0%), and all sexual partners (38.9%), respectively. In multivariable logistic regression analysis, having a senior high school education (AOR: 1.76; 95% CI: 0.88-3.12, p = 0.039), tertiary education or higher (AOR: 2.24; 95% CI: 0.86-3.23, p = 0.041), being an insertive sex partner (AOR: 1.26; 95% CI: 1.02-1.56, p = 0.029), being a sex worker (AOR: 1.41; 95% CI: 1.00-1.98, p = 0.048), buying sex from other males (AOR: 1.32; 95% CI: 1.03-1.70, p = 0.027), being a light drinker (AOR: 0.54; 95% CI: 0.42-0.68, p < 0.001), being a moderate drinker (AOR: 0.48; 95% CI: 0.30-0.78, p = 0.003), and possessing good HIV knowledge (AOR: 1.79; 95% CI: 1.46-2.20, p < 0.001) had higher odds of consistent condom use with lubricants. Being Islamic (AOR: 0.65; 95% CI: 0.49-0.87, p = 0.004), having a low income (AOR: 0.57; 95% CI: 0.42-0.77, p < 0.001), and easy access (AOR: 0.52; 95% CI: 0.37-0.72, p < 0.001) to condoms were positively associated with consistent condom use. This study found a low prevalence of consistent condom use with lubricants among the MSM population in Ghana. The study also found a range of socio-demographic, behavioral, and structural factors associated with consistent condom use with lubricants. This calls for very specific and unique public health interventions, such as developing a predictive model to identify and mitigate barriers to consistent condom use with lubricants.

Acceptability of a dapivirine levonorgestrel vaginal ring in two Phase 1 trials (MTN-030/IPM 041 and MTN-044/IPM 053/CCN019): Implications for multipurpose prevention technology development

End-user feedback early in product development is important for optimizing multipurpose prevention technologies for HIV and pregnancy prevention. We evaluated the acceptability of the 90-day dapivirine levonorgestrel ring (DPV-LNG ring) used for 14 days compared to a dapivirine-only ring (DVR-200mg) in MTN-030/IPM 041 (n = 23), and when used for 90 days cyclically or continuously in MTN-044/IPM 053/CCN019 (n = 25). We enrolled healthy, non-pregnant, HIV-negative women aged 18-45 in Pittsburgh, PA and Birmingham, AL (MTN-030 only). Self-reports of vaginal bleeding and adherence (ring removals, expulsions) were collected via daily short message service. Acceptability data were recorded in face-to-face interviews at study exit. We assessed differences in acceptability by product characteristics and adherence; and associations between baseline characteristics/demographics, number of bleeding days, adherence, and overall acceptability. Most (21/23) women in the 14-day MTN-030 study and about half (13/25) in the 90-day MTN-044 study liked their assigned rings. In MTN-030 there were no significant associations between any variables and overall acceptability of either ring. In MTN-044, women who disliked the DPV-LNG ring had a significantly higher incidence of unanticipated vaginal bleeding, and reporting that vaginal bleeding changes were unacceptable than those who liked it. Although we found no overall association between adherence and acceptability, significantly more women who disliked (versus liked) the DPV-LNG ring reported expulsions during toileting. The DPV-LNG ring could meet the needs of women seeking simultaneous protection from HIV and unintended pregnancy. Addressing issues related to vaginal bleeding and expulsions early in product development will likely enhance acceptability of the DPV-LNG ring. Trial registration: Clinical Trial Registration: MTN-030/IPM 041: ClinicalTrials.gov NCT02855346; MTN-044/IPM 053/CCN019: ClinicalTrials.gov NCT03467347.

Preferences for oral and injectable PrEP among qualitative sub-study participants in HPTN 084

BACKGROUND

HPTN 084 compared the safety and efficacy of long-acting injectable cabotegravir (CAB) to daily oral TDF/FTC for prevention of HIV-1 in uninfected African women. Like a similar trial in MSM/TGW (HPTN 083), the trial was stopped early for efficacy, expediting the need to consider introduction strategies for different populations. We examine survey and qualitative data from a four-country sub-study to examine oral and injectable PrEP acceptability and considerations for CAB access among African women.

METHODS

Participants completed baseline and follow-up surveys on HIV risk perception, sexual behavior. product acceptability and adherence during the blinded trial. Additionally, up to two in-depth interviews each with 73 sub-study participants explored product use and trial-related experiences, during the blinded and unblinded study periods. Using survey data, we classified participants as: engaged in female sex work (FSW), having multiple non-transactional partners, or monogamous. A study statistician identified participants' assigned study arm. We followed a thematic analysis process to read transcripts, develop a codebook and apply codes in NVivo to transcripts with intermittent intercoder reliability checks; using Excel matrices to explore differences across risk categories and study arms.

FINDINGS

Participants overwhelmingly preferred injections to pills, appreciating the ease, convenience, and privacy of a long-acting formulation. Many participants described challenges with contraceptive and/or study pill adherence, impeded by late night work, unexpected travel, or heavy drinking. Women in the TDF/FTC arm were more likely to describe side effects, compared to those in the CAB arm. Pain also varied widely by study arm. When considering post-trial access to CAB, limited PrEP knowledge, cost and concerns around stigma and poor service quality were potential access barriers.

CONCLUSION

Women's desire for privacy and ease of use outweighed injectable concerns, resulting in a strong preference for CAB. Cost and accessibility will need to be addressed by implementation programs.

Antiretroviral (ARV) Properties Dictate Long-Acting Release and Tissue Partitioning Behaviors in Multidrug Subcutaneous Implants

Subcutaneous implants can provide patients with long-acting, compliance-independent drug dosing. For this reason, subcutaneous implants have shown emerging interest in human immunodeficiency virus (HIV) prevention. However, any successful long-acting HIV-prevention device will require multidrug dosing, which poses a challenge for formulation considering the physicochemically diverse selection of antiretroviral (ARV) candidates. As a method that has shown the capacity of efficient multidrug delivery, we assessed electrospun fiber implants composed of three synergistically potent ARVs and a biodegradable polymer selected by in vitro release studies. In mice, subcutaneous electrospun fiber implants exhibit burst release of the more hydrophilic drugs maraviroc (MVC) and raltegravir (RAL), which could be reduced via simple prewash treatments of the implants. Over an extended 120 day time frame, fiber implants show drug-specific differences in release time frames and magnitudes in blood serum. However, end-point drug tissue concentrations show that the most hydrophobic drug etravirine (ETR) remains in high concentrations within the implant and in local skin tissue biopsies. Furthermore, ETR is found to be capable of significant partitioning into lymph nodes, the lower female reproductive tract, and the rectum. Topologically smooth film implants also exhibit the same drug-dependent trends. Therefore, we illustrate that drug release and drug tissue partitioning are largely dictated by drug properties. Further, we find that the properties of ETR enable significant drug quantities within the tissues most relevant to HIV protection. Evidence from this work emphasizes the need for a greater focus on drug properties and prodrug strategies to enable relevant, extended, and targeted drug release.

"Killing two birds with one stone" - a qualitative study on women's perspectives on the dual prevention pill in Johannesburg, South Africa

BACKGROUND

HIV incidence remains high in South Africa, with ~ 60% of all new HIV infections among adolescent girls and women (Country factsheets HIV and AIDS Estimates, 2022). Oral pre-exposure prophylaxis (PrEP), approved for HIV prevention in South Africa since 2015, is hampered by low uptake and adherence, particularly among adolescent girls and young women (AGYW). Combining oral PrEP with oral contraceptives could increase PrEP uptake, persistence and address unmet needs for contraception. We investigated the acceptability of a dual prevention pill (DPP), combining oral PrEP and a combined oral contraceptive (COC) for HIV and pregnancy prevention among women in Johannesburg, South Africa.

METHODS

Between March-July 2021, we conducted 12 focus group discussions (FGDs) with adolescent girls and women (n = 74) aged 16-40 stratified by ages (16-17, 18-24, 25-40), half of whom were COC users. We explored adolescent girls and women's opinions about the DPP concept, existing HIV and pregnancy prevention options, and input on perceived facilitators and barriers to DPP use. FGDs were conducted in English or isiZulu, using a standardized interview guide. FGDs were audio-recorded, transcribed to English and analyzed using ethnographic content analysis.

RESULTS

The majority viewed the DPP favorably as a multipurpose option preventing unplanned pregnancy and HIV. Most saw it as a convenient "two-in-one" solution, requiring one clinic visit for both PrEP and COCs. AGYW were viewed as the most likely to benefit from the DPP due to the likelihood of multiple partners and unplanned sex, possibly preventing school dropout from unplanned pregnancy or HIV acquisition. The DPP was perceived to be more reliable than condoms, especially when condom negotiation is limited. Benefits were also seen by participants in rape cases, protecting against pregnancy and HIV. DPP use barriers included side effect concerns, unsupportive partners and judgmental healthcare providers.

CONCLUSIONS/SIGNIFICANCE

The DPP was perceived as acceptable for HIV and pregnancy prevention to AGYW in Johannesburg and its dual indications helpful in supporting improved PrEP uptake and persistence. DPP implementation programs need to consider solutions to potential barriers, like education on DPP benefits, coupled with reliable side effect support and healthcare provider sensitization as part of routine sexual health services to encourage uptake and adherence.

Assessing the acceptability of, adherence to and preference for a dual prevention pill (DPP) for HIV and pregnancy prevention compared to oral pre-exposure prophylaxis (PrEP) and oral contraception taken separately: protocols for two randomised, controlled, cross-over studies in South Africa and Zimbabwe

INTRODUCTION

Oral pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention method; however, uptake and persistence have been low among southern African women. A dual prevention pill (DPP) that combines PrEP with oral contraception (OC) may increase PrEP use and better meet women's sexual and reproductive health needs. We will gauge the DPP's acceptability in two cross-over clinical trials.

METHODS AND ANALYSIS

PC952 (Zimbabwe) and PC953 (South Africa) will compare acceptability, adherence and preference for an over-encapsulated DPP versus PrEP and OCs taken separately. HIV-negative, non-pregnant cisgender females in Johannesburg, South Africa (n=96, 16-40 years) and Harare, Zimbabwe (n=30, 16-24 years) will be randomised 1:1 to the order of regimens-DPP or two separate tablets-each used for three 28-day cycles, followed by a 6-month choice period in South Africa. Monthly clinic visits include HIV and pregnancy testing; safety assessments and risk reduction and adherence counselling. We will assess adherence (monthly) based on tenofovir diphosphate drug levels in dried blood spots and by self-report. We will evaluate acceptability (monthly) and preference (end of cross-over) via computer-assisted self-interviewing and in-depth interviews with a subset of participants. Data collection started in September 2022 and ended in January 2024.

ETHICS AND DISSEMINATION

PC952 was approved by the Ministry of Health and Child Care, Medical Research Council, Research Council and Medicines Control Authority of Zimbabwe; the Chitungwiza City Health Ethics Committee; and the Joint Research Ethics Committee for the University of Zimbabwe Faculty of Medicine and Health Sciences and Parirenyatwa Group of Hospitals. PC953 was approved by the South African Health Products Regulatory Authority and the University of the Witwatersrand's Human Research Ethics Committee. The Population Council IRB approved both studies. We will disseminate results in open-access journals, clinical trials registries, and at local and international meetings and conferences.

TRIAL REGISTRATION NUMBERS

NCT04778514, NCT04778527.

Utilization of HIV Pre-exposure Prophylaxis and Associated Factors Among Female Sex Workers in Bahir Dar City, North-West Ethiopia, Cross-sectional Study, 2022

Objective

This study aimed to assess the utilization of HIV pre-exposure prophylaxis and associated factors among commercial female sex workers in Bahir Dar City, Northwest Ethiopia, in 2022.

Methods

An institution-based cross-sectional study was conducted in Bahir Dar City from November 1 to 30, 2022. The random sampling technique was used to select 396 commercial female sex workers. Kobo Collector was used to gather the data, which was then exported to STATA 14 for analysis. In bivariate regression analysis, all variables with a P-value of <0.2 were entered into multivariable logistic regression. Multivariable logistic regression variables with P-values ≤0.05 at a 95% confidence interval were declared to be significantly linked with the utilization of HIV pre-exposure prophylaxis.

Results

In this study, 183 (46.2%) (95%CI: 41.33-51.16) of respondents utilized HIV pre-exposure prophylaxis. Educational status: secondary and above (AOR: 2.18, 95%CI: 1.05-4.53). Age of sex workers 26-36 (AOR: 0.20, 95%CI: 0.17-0.84); experience of sex work 3-5 years (AOR: 0.25, 95%CI: 0.24-0.83); and having good knowledge (AOR: 4.98, 95%CI: 3.90-10.65) were significantly associated with the utilization of HIV pre-exposure prophylaxis.

Conclusion

In this study, HIV pre-exposure prophylaxis was not widely used by commercial female sex workers. Therefore, social and behavioral change communication strategies focus on creating awareness and building knowledge on HIV pre-exposure prophylaxis utilization.

Assessing HIV Pre-exposure Prophylaxis Uptake and Retention Amongst Young Females in Gauteng Province

Although roll-out of HIV pre-exposure prophylaxis (PrEP) has been reported to have changed contexts of HIV risk in areas where it was well-implemented. The rate of its uptake and retention amongst young females has not been described in Gauteng Province. This paper aimed at assessing PrEP uptake and retention among young females in Gauteng Province. Total of young females who tested HIV across five clinics from 01/January/2017 to 31/December/2020 was 19,671 with 17,937 tested HIV negative. Of the HIV tested negative, PrEP was initiated to 1307 (7%). The analysis revealed that 27% of young females returned for their first follow up visit after PrEP initiation, while third month declined to 14%, fourth month to 11%, and fifth month to 3%, sixth month to 2% and seventh month at 1% and from the eighth month, the rate of follow up was 0%. Uptake and retention of PrEP was low among young females as measured against the total tested HIV negative.

Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004

Introduction: Research has begun to examine human immunodeficiency virus (HIV) prevention strategies within the Ghanaian context. Still, little is known about specific populations such as gay, bisexual, and other cisgender men who have sex with men (GBMSM) living in slum communities. We studied HIV prevention strategies such as condoms and preexposure prophylaxis (PrEP) in slum communities and the awareness and willingness to use these choices among GBMSM. This qualitative study examines HIV prevention strategies, specifically examining PrEP and condom use behaviors among GBMSM in Ghana. Methods: We conducted in-depth face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi cities in Ghana. Data were analyzed through a summative content analysis with multiple reviewers to develop codes. Data were collected from participants in January 2022. Results: We found the fear and perceived risk of infection were motivators for consistent condom use, especially during anal sex. GBMSM living with HIV receiving antiretroviral therapy were more inclined to use condoms. We found motivations for using PrEP were influenced by the type of sexual activity and a history of negative HIV status. Also, the barriers to PrEP for GBMSM included limited access to healthcare facilities and the distance to these facilities. Conclusions: To improve condom and PrEP access and uptake, we recommend addressing structural barriers by increasing the number of health facilities and implementing targeted interventions to address the lack of information on HIV awareness and prevention. Involving peer educators may also effectively promote HIV prevention strategies, especially in communities with limited access to healthcare such as slums. Overcoming these access constraints could significantly enhance awareness and prevention of HIV, leading to improved health outcomes for GBMSM living in slum communities.

Deep learning for topical trend discovery in online discourse about Pre-Exposure Prophylaxis (PrEP)

Pre-Exposure Prophylaxis (PrEP) interventions are increasingly prevalent on social media. These data can be mined for insights about PrEP that may not be as apparent in surveys including personal musings about PrEP and barriers/facilitators to PrEP uptake. This study explores online discourse about PrEP using an interdisciplinary public health and computational informatics approach. We collected (N = 4,020) tweets using Twitter's Application Programming Interface (API). These data underwent a three-step neural network/deep learning process to identify clusters within these tweets and relative similarity/dissimilarity between clusters. We identified 25 distinct clusters from our original collection of tweets. These clusters represent general information about PrEP, how PrEP is communicated among diverse groups, and potential pockets of misinformation and disinformation regarding PrEP. Specific clusters of interest include discussions of medication side effects, social perception of PrEP usage, and concerns with costs and barriers to access of PrEP interventions. Our approach revealed diverse ways PrEP is contextualized online. Importantly this information can be leveraged to identify points of possible intervention for disinformation and misinformation about PrEP.

PrEP policy implementation gaps and opportunities in Latin America and the Caribbean: a scoping review

Background

Pre-exposure prophylaxis (PrEP) is an important tool for HIV prevention in Latin America and the Caribbean (LAC). Yet, little is known about the PrEP policies landscape in the region. Addressing this gap, this scoping review assessed current PrEP policies throughout LAC to better understand existing PrEP implementation gaps and identify opportunities to improve access.

Methods

We conducted a scoping review, using a modified PRISMA extension, through 28 July 2022, to identify country-level PrEP policies. Data were collected in English, Spanish, French, and Portuguese utilizing online platforms for screening and data extraction (Google Forms, Zotero, and Excel). Extracted data were divided by data source, including country-level government policies, gray literature, and peer-reviewed literature, with at least one full-text reviewer and data extractor per publication. An iterative summative content analysis was performed to compare and interpret themes across phases and data sources.

Results

Of the 33 countries in LAC, 22 (67%) had policies approving daily oral PrEP for HIV prevention, which outlined specific key populations, including men who have sex with men, transgender women, sex workers, and serodiscordant couples. Generic tenofovir disoproxil fumarate/emtricitabine has been approved in 15 of the 33 countries, and 13 of the 33 countries have incorporated PrEP into their public health system. No countries were found to have approved cabotegravir. Costing data were reported by only one country, Ecuador, in its national health ministry guidelines. Findings also document a lag between the media/gray-literature announcement of PrEP and implementation of policies.

Conclusion

Findings underscore significant advances in PrEP policies in the region and signal opportunities for greater PrEP implementation. Since 2017, an increasing number of countries have begun to provide PrEP to communities at heightened need, although significant gaps remain. Policy approval is a key step to further increasing access to PrEP in LAC, necessary to reduce the burden of HIV in LAC, specifically among marginalized populations.

Acceptability of an intravaginal ring for simultaneously preventing HIV infection and pregnancy: Qualitative findings of the Kisumu Combined Ring Study, 2019

Multipurpose prevention technology intravaginal rings (MPT IVRs) may offer a promising solution for addressing women's multiple sexual and reproductive health needs. We describe MPT IVR acceptability perspectives and examine user experiences of 25 cisgender women aged 18-34 years enrolled in a phase IIa randomized, partially blinded, placebo-controlled evaluation of tenofovir-based IVRs with and without contraceptive co-formulation. All took part in an individual, audio-recorded, semi-structured qualitative interview. A thematic analysis of transcribed interviews was completed in MaxQDA. Participants shared little to no knowledge of or experience with IVRs prior to joining the study. Four MPT IVR themes were identified: physical well-being, method reliability, personal management, and societal endorsement. Commonly cited of concern, but less described as being experienced, were physical discomforts (e.g., painful insertion/removal; inability to carry out daily activities/chores; foreign body sensation; expulsion; sexual interference, or debilitating side effects). Uncertainty regarding efficacy influenced perspectives about intended prevention benefits. Personal choices in managing reproduction and sexual behaviors had to be congruent with sociocultural values and norms for acceptance beyond the individual user level. Participants viewed broader community acceptance as likely to be mixed given community opposition to the use of modern family planning methods. They also shared concerns that IVR use could lead to infertility, especially among nulliparous women, or that it would encourage premarital sex or high-risk sexual behaviors among adolescent and young women. While a MPT IVR may not be suitable for all women, first-hand testimonials could help influence collective receptivity. Additional community acceptability research is needed. Clinical Trial Registration The study is registered at http://ClinicalTrials.gov under the identifier NCT03762382.

Understanding the Association between PrEP Stigma and PrEP Cascade Moderated by the Intensity of HIV Testing

(1) Background: In the U.S., men who have sex with men (MSM) account for the majority of new HIV infections. On the other hand, pre-exposure prophylaxis (PrEP) is an effective strategy to curb HIV transmission, but it is widely underutilized. It is unknown how stigma affects PrEP care in the context of other HIV prevention strategies. (2) Methods: We included a total of 318 MSM in the current analysis. We employed bivariate and multivariable analyses to assess the association between PrEP stigma and PrEP cascade while controlling for potential confounders on each specific pathway. We further used a series of moderation analyses based upon the intensity of HIV testing within different timeframes to assess the association between PrEP stigma and PrEP cascade. (3) Results: Compared with MSM who used PrEP, those who never used PrEP reported higher internalized and vicarious PrEP stigma. Internalized PrEP stigma has significantly reduced the likelihood of PrEP willingness and PrEP uptake among this group. The trend analysis showed significant trend patterns across different frequencies of HIV testing. (4) Conclusions: A structural-level reform is urgently needed to turn the HIV service encounters into opportunities to facilitate and optimize the PrEP cascade among this group who may benefit from PrEP use.

The Role of Families in Adolescent and Young Adults' PrEP Use

While pre-exposure prophylaxis (PrEP) is a key HIV prevention tool for adolescents and young adults (AYAs), its initiation and sustained use is shaped by AYAs' unique social contexts, including family. We explored the role of families in AYAs' PrEP use through qualitative in-depth interview (IDI) data from iPrevent, an end-user study designed to identify factors that could optimize PrEP adherence among South African youth (18-24 years old). These data were collected using a semi structured guide and were analysed using an inductive approach. Several themes describing family influence on AYAs' PrEP use emerged including family support; family attitude towards PrEP; and the family's ability to obviate PrEP disclosure challenges. In addition, dimensions of family closeness, categorized as 'close', 'in-between' and 'loose-knit,' appeared important in contextualizing family influence on AYAs' PrEP use. We found that family remains a proximal and fundamental social system in which AYA are socialized and greater family engagement could aid PrEP implementation in this priority population.

Kidney function in tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis users: a systematic review and meta-analysis of published literature and a multi-country meta-analysis of individual participant data

BACKGROUND

Previous WHO guidance on tenofovir disoproxil fumarate-based oral pre-exposure prophylaxis (PrEP) suggests measuring creatinine levels at PrEP initiation and regularly afterwards, which might represent barriers to PrEP implementation and uptake. We aimed to systematically review published literature on kidney toxicity among tenofovir disoproxil fumarate-based oral PrEP users and conducted an individual participant data meta-analysis (IPDMA) on kidney function among PrEP users in a global implementation project dataset.

METHODS

In this systematic review and meta-analysis we searched PubMed up to June 30, 2021, for randomised controlled trials (RCTs) or cohort studies that reported on graded kidney-related adverse events among oral PrEP users (tenofovir disoproxil fumarate-based PrEP alone or in combination with emtricitabine or lamivudine). We extracted summary data and conducted meta-analyses with random-effects models to estimate relative risks of grade 1 and higher and grade 2 and higher kidney-related adverse events, measured by elevated serum creatinine or decline in estimated creatinine clearance or estimated glomerular filtration rate. The IPDMA included (largely unpublished) individual participant data from 17 PrEP implementation projects and two RCTs. Estimated baseline creatinine clearance and creatinine clearance change after initiation were described by age, gender, and comorbidities. We used random-effects regressions to estimate the risk in decline of creatinine clearance to less than 60 mL/min.

FINDINGS

We identified 62 unique records and included 17 articles reporting on 11 RCTs with 13 523 participants in meta-analyses. PrEP use was associated with increased risk of grade 1 and higher kidney adverse events (pooled odds ratio [OR] 1·49, 95% CI 1·22-1·81; I2=25%) and grade 2 and higher events (OR 1·75, 0·68-4·49; I2=0%), although the grade 2 and higher association was not statistically significant and events were rare (13 out of 6764 in the intervention group vs six out of 6782 in the control group). The IPDMA included 18 676 individuals from 15 countries (1453 [7·8%] from RCTs) and 79 (0·42%) had a baseline estimated creatinine clearance of less than 60 mL/min (increasing proportions with increasing age). Longitudinal analyses included 14 368 PrEP users and 349 (2·43%) individuals had a decline to less than 60 mL/min creatinine clearance, with higher risks associated with increasing age and baseline creatinine clearance of 60·00-89·99 mL/min (adjusted hazard ratio [aHR] 8·49, 95% CI 6·44-11·20) and less than 60 mL/min (aHR 20·83, 12·83-33·82).

INTERPRETATION

RCTs suggest that risks of kidney-related adverse events among tenofovir disoproxil fumarate-based oral PrEP users are increased but generally mild and small. Our global PrEP user analysis found varying risks by age and baseline creatinine clearance. Kidney function screening and monitoring might focus on older individuals, those with baseline creatinine clearance of less than 90 mL/min, and those with kidney-related comorbidities. Less frequent or optional screening among younger individuals without kidney-related comorbidities may reduce barriers to PrEP implementation and use.

FUNDING

Unitaid, Bill & Melinda Gates Foundation, WHO.

The Impact of Genital Ulcers on HIV Transmission Has Been Underestimated—A Critical Review

In the early 1990s, several observational studies determined that genital ulcer disease (GUD), in either the index or the exposed person, facilitates HIV transmission. Several meta-analyses have since presented associated risk ratios (RR) over the baseline per-act transmission probability (PATP) usually in the range of 2–5. Here we review all relevant observational studies and meta-analyses, and show that the estimation of RRs was, in most cases, biased by assuming the presence of GUD at any time during long follow-up periods, while active genital ulcers were present in a small proportion of the time. Only two studies measured the GUD co-factor effect in PATPs focusing on acts in which ulcers were present, and both found much higher RRs (in the range 11–112). We demonstrate that these high RRs can be reconciled with the studies on which currently accepted low RRs were based, if the calculations are restricted to the actual GUD episodes. Our results indicate that the effect of genital ulcers on the PATP of HIV might be much greater than currently accepted. We conclude that the medical community should work on the assumption that HIV risk is very high during active genital ulcers.

Infectious RNA: Human Immunodeficiency Virus (HIV) Biology, Therapeutic Intervention, and the Quest for a Vaccine

Different mechanisms mediate the toxicity of RNA. Genomic retroviral mRNA hijacks infected host cell factors to enable virus replication. The viral genomic RNA of the human immunodeficiency virus (HIV) encompasses nine genes encoding in less than 10 kb all proteins needed for replication in susceptible host cells. To do so, the genomic RNA undergoes complex alternative splicing to facilitate the synthesis of the structural, accessory, and regulatory proteins. However, HIV strongly relies on the host cell machinery recruiting cellular factors to complete its replication cycle. Antiretroviral therapy (ART) targets different steps in the cycle, preventing disease progression to the acquired immunodeficiency syndrome (AIDS). The comprehension of the host immune system interaction with the virus has fostered the development of a variety of vaccine platforms. Despite encouraging provisional results in vaccine trials, no effective vaccine has been developed, yet. However, novel promising vaccine platforms are currently under investigation.

Willingness to take and ever use of pre-exposure prophylaxis among female sex workers in Ghana

Pre-exposure prophylaxis (PrEP) is a drug taken by people who are human immunodeficiency virus (HIV) negative and at increased risk of acquiring HIV. It's an effective intervention for HIV prevention. This study seeks to report on the prevalence and determinants of willingness to take and ever use of PrEP among female sex workers (FSW) in Ghana.The data analyzed was obtained from the Integrated Bio-behavioral Surveillance Survey conducted across the 16 regions of Ghana in 2020. Analysis was only performed on FSW who were tested negative to HIV and were sexually active. All included variables were described using medians, percentages, and graphs. Bayesian adjusted odds ratios and 95% credible intervals were estimated using a Bayesian generalized linear model via the binomial family of distributions under the logit link function.Of the 5107 FSW with complete data on willingness to use PrEP, 2737 (53.59%) reported their willingness to take PrEP. Out of the 998 respondents who have ever heard of PrEP only 64 (6.39%) have ever used PrEP. The median age of the respondents was 25 years. People with no comprehensive knowledge of HIV and acquired immunodeficiency syndrome as well as those who entered into the FSW business at age less than 25 years; 946 (34.56%) and 2181 (79.65%) respectively were more willing to take PrEP. FSW from 6 out of the 16 regions of Ghana have never used PrEP. A statistically significant difference between those who entered the sex work at age less than 25 years and those within 25 to 34 years was observed. About 23% of FSWs who had been screened for Sexually Transmitted Infections were more likely to take PrEP.Respondents with lesser age and no comprehensive knowledge of HIV were more willing to take PrEP. The willingness to accept PrEP among FSWs in Ghana is modest. However, utilization is low. Advocacy or intervention programs are required to improve uptake of PrEP.

Rectal tissue and vaginal tissue from intravenous VRC01 recipients show protection against ex vivo HIV-1 challenge

BackgroundVRC01, a potent, broadly neutralizing monoclonal antibody, inhibits simian-HIV infection in animal models. The HVTN 104 study assessed the safety and pharmacokinetics of VRC01 in humans. We extend the clinical evaluation to determine intravenously infused VRC01 distribution and protective function at mucosal sites of HIV-1 entry.MethodsHealthy, HIV-1-uninfected men (n = 7) and women (n = 5) receiving VRC01 every 2 months provided mucosal and serum samples once, 4-13 days after infusion. Eleven male and 8 female HIV-seronegative volunteers provided untreated control samples. VRC01 levels were measured in serum, secretions, and tissue, and HIV-1 inhibition was determined in tissue explants.ResultsMedian VRC01 levels were quantifiable in serum (96.2 μg/mL or 1.3 pg/ng protein), rectal tissue (0.11 pg/ng protein), rectal secretions (0.13 pg/ng protein), vaginal tissue (0.1 pg/ng protein), and cervical secretions (0.44 pg/ng protein) from all recipients. VRC01/IgG ratios in male serum correlated with those in paired rectal tissue (r = 0.893, P = 0.012) and rectal secretions (r = 0.9643, P = 0.003). Ex vivo HIV-1Bal26 challenge infected 4 of 21 rectal explants from VRC01 recipients versus 20 of 22 from controls (P = 0.005); HIV-1Du422.1 infected 20 of 21 rectal explants from VRC01 recipients and 12 of 12 from controls (P = 0.639). HIV-1Bal26 infected 0 of 14 vaginal explants of VRC01 recipients compared with 23 of 28 control explants (P = 0.003).ConclusionIntravenous VRC01 distributes into the female genital and male rectal mucosa and retains anti-HIV-1 functionality, inhibiting a highly neutralization-sensitive but not a highly resistant HIV-1 strain in mucosal tissue. These findings lend insight into VRC01 mucosal infiltration and provide perspective on in vivo protective efficacy.FundingNational Institute of Allergy and Infectious Diseases and Bill & Melinda Gates Foundation.

Initial implementation of PrEP in Zambia: health policy development and service delivery scale-up

INTRODUCTION

Daily pre-exposure prophylaxis (PrEP) for HIV prevention is highly effective, but not yet widely deployed in sub-Saharan Africa. We describe how Zambia developed PrEP health policy and then successfully implemented national PrEP service delivery.

POLICY DEVELOPMENT

Zambia introduced PrEP as a key strategy for HIV prevention in 2016, and established a National PrEP Task Force to lead policy advocacy and development. The Task Force was composed of government representatives, regulatory agencies, international donors, implementation partners and civil society organisations. Following an implementation pilot, PrEP was rolled out nationally using risk-based criteria alongside a national HIV prevention campaign.

NATIONAL SCALE-UP

In the first year of implementation, ending September 2018, 3626 persons initiated PrEP. By September 2019, the number of people starting PrEP increased by over sixfold to 23 327 persons at 728 sites across all ten Zambian provinces. In the first 2 years, 26 953 clients initiated PrEP in Zambia, of whom 31% were from key and priority populations. Continuation remains low at 25% and 11% at 6 and 12 months, respectively.

LESSONS LEARNT

Risk-based criteria for PrEP ensures access to those most in need of HIV prevention. Healthcare worker training in PrEP service delivery and health needs of key and priority populations is crucial. PrEP expansion into primary healthcare clinics and community education is required to reach full potential. Additional work is needed to understand and address low PrEP continuation. Finally, a task force of key stakeholders can rapidly develop and implement health policy, which may serve as a model for countries seeking to implement PrEP.

Estimating the market size for a dual prevention pill: adding contraception to pre-exposure prophylaxis (PrEP) to increase uptake

INTRODUCTION

Uptake of oral pre-exposure prophylaxis (PrEP) remains low. The objective of this analysis was to estimate the potential market size in priority sub-Saharan African countries for a 28-day dual prevention pill (DPP) regimen containing the active pharmaceutical ingredients in oral PrEP and oral contraceptive pills (OCPs) for the prevention of HIV and unintended pregnancy.

METHODS

We selected 15 countries in sub-Saharan Africa for analysis. Population estimates were based on United Nations Population Division data from 2017. Low, medium and high rates (range 0.25% to 25%) of estimated conversion from current contraceptive method to the DPP were applied by country based on HIV prevalence (≥10% vs <10%), current contraceptive method (OCP, condom or unmet need for contraception) and age group (15-24 or 25-49 years).

RESULTS

In these 15 countries, between 250 000 and 1.25 million women could switch from their current contraceptive method to the DPP. Given that current PrEP use in the 15 countries combined is estimated to be 113 250 (women and men), the most conservative market size estimate would more than double the number of women currently using PrEP.

CONCLUSIONS

By leveraging the existing market for OCPs and assuming modest conversion from condom users and women with an unmet need for contraception, the DPP could lead to a 2- to 10-fold increase in PrEP usage in these 15 sub-Saharan African countries, expanding the broader public health benefit of this proven HIV prevention strategy.

HIV Pre-exposure Prophylaxis in the LGBTQ Community: A Review of Practice and Places

One in six bisexual and gay men will be diagnosed with HIV in their lifetime (Human Rights Campaign, 2017). Without a vaccine or cure, prevention may be the best tool to control the HIV pandemic. Since 2012, the World Health Organization (WHO) recommends HIV pre-exposure prophylaxis (PrEP) for a high-risk population. To this day, in the United States (U.S.), the group with the highest risk is MSM (men who have sex with other men) that have condom-less sexual intercourse (Center for Disease Control and Prevention, 2019). In fact, in 2018, over 50% of all HIV infections occurred in MSM and members of the LGBT community. A systematic review was conducted using PubMed, Google Scholar, and Cochrane Library. The inclusive criteria were articles published from 2015-2020, focusing specifically on HIV PrEP among the members of the LGBTQ+ community. The keywords for our search were "Pre-exposure prophylaxis," "HIV," "men who have sex with other men" (MSM), "Bisexual," "transgender." A total of 25 articles met the inclusion criteria. About 50% of the articles focused on MSM while others highlighted bisexual and transgender women. Globally, PrEP is a priority. Programs to educate and promote its use are being developed, but challenges are present regarding access to PrEP and its maintenance for longer than 12 months. In the U.S., PrEP programs started in 2012, intending to promote and educate. Research shows that more than 60% of the high-risk patients are willing to try PrEP if they are correctly educated, showing that physicians were not doing a thorough job educating their patients. PrEP is essential for preventing the transmission of HIV among the LGBTQ+ subpopulation. Existing gaps need to be bridged to create or improve to educate high-risk populations and physicians on HIV PrEP.

Utilizing Alternative Testing Technology for Human Immunodeficiency Virus (HIV) in the COVID era

Purpose of Review

With the onset of the Coronavirus disease 2019 (COVID-19) pandemic, in-person human immunodeficiency virus (HIV) testing is no longer easily accessible. Therefore, alternative testing technologies must be considered and implemented on a large scale to continue prevention efforts. This review seeks to describe the benefits of utilizing at-home HIV testing technologies, traditionally deemed an alternative form of testing.

Recent Findings

Utilizing at-home testing technology during the COVID-19 pandemic overcomes novel and previously identified barriers to HIV testing.

Summary

Ensuring access to HIV testing is imperative to long-term prevention goals. With the Ending the HIV Epidemic (EHE) initiative in the USA targeting achievement by 2030, obstacles to HIV testing must be addressed to ensure its success. Implementing alternative testing technology more broadly allows for continued prevention efforts for HIV in light of COVID era restrictions.

Potential Impact and Cost-Effectiveness of Condomless-Sex-Concentrated PrEP in KwaZulu-Natal Accounting for Drug Resistance

INTRODUCTION

Oral preexposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation.

METHODS

We calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (1) PrEP availability for adolescent girls and young women aged 15-24 years and female sex workers, and (2) availability for everyone aged 15-64 years. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programs.

RESULTS

In the context of PrEP use in adults aged 15-64 years, there was a predicted 33% reduction in incidence and 36% reduction in women aged 15-24 years. PrEP was cost-effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance.

CONCLUSIONS

PrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.

Addressing Antiretroviral Drug Resistance with Host-Targeting Drugs-First Steps towards Developing a Host-Targeting HIV-1 Assembly Inhibitor

The concerning increase in HIV-1 resistance argues for prioritizing the development of host-targeting antiviral drugs because such drugs can offer high genetic barriers to the selection of drug-resistant viral variants. Targeting host proteins could also yield drugs that act on viral life cycle events that have proven elusive to inhibition, such as intracellular events of HIV-1 immature capsid assembly. Here, we review small molecule inhibitors identified primarily through HIV-1 self-assembly screens and describe how all act either narrowly post-entry or broadly on early and late events of the HIV-1 life cycle. We propose that a different screening approach could identify compounds that specifically inhibit HIV-1 Gag assembly, as was observed when a potent rabies virus inhibitor was identified using a host-catalyzed rabies assembly screen. As an example of this possibility, we discuss an antiretroviral small molecule recently identified using a screen that recapitulates the host-catalyzed HIV-1 capsid assembly pathway. This chemotype potently blocks HIV-1 replication in T cells by specifically inhibiting immature HIV-1 capsid assembly but fails to select for resistant viral variants over 37 passages, suggesting a host protein target. Development of such small molecules could yield novel host-targeting antiretroviral drugs and provide insight into chronic diseases resulting from dysregulation of host machinery targeted by these drugs.

Conditional expanding post-exposure prophylaxis: a potential new tool for tuberculosis control

The latest consolidated guideline on tuberculosis (TB) preventive treatment, released by World Health Organization (WHO) in 2020, strongly recommended that children aged <5 years who are household contacts of people with bacteriologically confirmed pulmonary TB and who are found not to have active TB should be recommended for TB preventive treatment even if TB infection testing is unavailable [1]. That means preventative treatment should be administrated to the children aged <5 years once exposure has occurred. The concept of such post-exposure prophylaxis (PEP) has been successfully practised for HIV prevention among at-risk individuals with occupational exposure or non-occupational exposure [2]. For TB, PEP is still a new concept, here we raise a proposal to explore whether PEP could be scaled up to the other high-risk populations as a potential tool to accelerate the achievement of the END TB global goal [3]. The development of a new strategy requires systematic research and sufficient evidence; hence, we are only undertaking some preliminary discussion here.

For individuals with high risk of exposure and thereafter developing and transmitting active tuberculosis, conditional post-exposure prophylaxis might be a potential tool for tuberculosis controlhttps://bit.ly/39qHHh4

Modular Approaches to Understand the Immunobiology of Human Immunodeficiency Virus Latency

Despite advances in slowing the progression of acquired immunodeficiency syndrome (AIDS), there is no viable cure for human immunodeficiency virus (HIV). The challenge toward a cure is mainly the formation and maintenance of a latent reservoir of cells that harbor the virus in both replication-competent and replication-defective states. This small niche of quiescent cells has been identified to reside primarily in quiescent and memory CD4⁺ T cells, but parameters that could reliably distinguish an infected T cell from an uninfected one, if any, are not clear. In addition, the migratory properties and specific anatomical reservoirs of latent T cells are difficult to measure at a high resolution in humans. A functional cure of HIV would require targeting this population using innovative new clinical strategies. One constraint toward the empirical development of such approaches is the absence of a native small animal model for AIDS. Since HIV does not efficiently infect murine cells, probing molecular-genetic questions involving latently infected T cells homing to deep tissue sites, interacting with stroma and persisting through different treatment regimens, is challenging. The goal of this article is to discuss how examining the dynamics of T cells in mouse models can provide a framework for effectively studying these questions, even without infecting mice with HIV. The inflammatory and cytokine milieu found in early human HIV infections are being increasingly understood as a result of clinical measurements. Mouse studies that recreate this milieu can potentially be used to subsequently map the fate of T cells activated in this context as well as their migratory routes. In essence, such a framework could allow complementary studies in mice to enhance our understanding of aspects of the biology of HIV latency. This can be the basis of a modular approach to small animal HIV modeling, amenable to preclinical curative strategy development.

Acceptability, safety, and patterns of use of oral tenofovir disoproxil fumarate and emtricitabine for HIV pre-exposure prophylaxis in South African adolescents: an open-label single-arm phase 2 trial

BACKGROUND

HIV incidence among adolescents in southern Africa remains unacceptably high. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention intervention but there are few data on its implementation among adolescents. We aimed to investigate the safety, feasibility, and acceptability of PrEP with oral tenofovir disoproxil fumarate and emtricitabine as part of a comprehensive HIV prevention package in an adolescent population in South Africa.

METHODS

This open-label single-arm phase 2 study (PlusPills) was done in two research clinics in Cape Town and Johannesburg, South Africa. Adolescents aged 15-19 years were recruited into the study through recruitment events and outreach in the community. Potential participants were eligible for enrolment if they reported being sexually active. Exclusion criteria were a positive test for HIV or pregnancy at enrolment, breastfeeding, or any relevant co-morbidities. Participants were given oral tenofovir disoproxil fumarate and emtricitabine for PrEP to take daily for the first 12 weeks and were then given the choice to opt in or out of PrEP use at three monthly intervals during scheduled clinic visits. Participants were invited to monthly visits for adherence counselling and HIV testing during the study period. The primary outcomes were acceptability, use, and safety of PrEP. Acceptability was measured by the proportion of participants who reported willingness to take up PrEP and remain on PrEP at each study timepoint. Use was defined as the number of participants who continued to use PrEP after the initial 12-week period until the end of the study (week 48). Safety was measured by grade 2, 3, and 4 laboratory and clinical adverse events using the Division of AIDS table for grading the severity of adult and paediatric adverse events, version 1.0. Dried blood spot samples were collected at each study time-point to measure tenofovir diphosphate concentrations. This trial is registered with ClinicalTrials.gov, NCT02213328.

FINDINGS

Between April 28, 2015, and Nov 11, 2016, 244 participants were screened, and 148 participants were enrolled (median age was 18 years; 99 participants [67%] were female) and initiated PrEP. PrEP was stopped by 26 of the 148 (18%) participants at 12 weeks. Cumulative PrEP opt-out, from the total cohort, was 41% (60 of 148 participants) at week 24 and 43% (63 of 148 participants) at week 36. PrEP was well tolerated with only minor adverse events (grade 2) thought to be related to study drug, which included headache (n=4, 3%), gastrointestinal upset (n=8, 5%), and skin rash (n=2, 1%). Two participants (1%) experienced grade 3 weight loss, which was deemed related to the study drug and resolved fully when PrEP was discontinued. Tenofovir diphosphate concentrations were detectable (>16 fmol/punch) in dried blood spot samples in 108 (92%) of 118 participants who reported PrEP use at week 12, in 74 (74%) of 100 participants at week 24, and in 22 (59%) of 37 participants by the study end at week 48.

INTERPRETATION

In this cohort of self-selected South African adolescents at risk of HIV acquisition, PrEP appears safe and tolerable in those who continued use. PrEP use decreased throughout the course of the study as the number of planned study visits declined. Adolescents in southern Africa needs access to PrEP with tailored adherence support and possibly the option for more frequent and flexible visit schedules.

FUNDING

National Institute of Allergy and Infectious Diseases of the US National Institutes of Health.

Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Men Who Have Sex with Men (MSM): A Scoping Review on PrEP Service Delivery and Programming

Pre-exposure prophylaxis (PrEP) is an evidence-based new biomedical HIV prevention intervention, which involves the pre-emptive use of daily (or event-based) antiretroviral drugs, to reduce risk of HIV acquisition if exposed. PrEP has recently been positioned as an integral prevention tool to reduce HIV acquisition risk among men who have sex with men (MSM) at country-level and within global prevention strategies. Given this global scale up of PrEP, we conducted a scoping review of extant international literature documenting service related perspectives, models and lessons learnt in PrEP programming for MSM. A systematic search of literature was conducted, and restricted to English language records in the timeframe 2008 to February 2019. Eligibility criteria centered on whether studies broadly described PrEP programming and service delivery for MSM as well as health communication. Following exclusion of ineligible records and removal of duplicates, 84 records were charted and thematically analysed according to scoping review methods. Four themes emerged from the thematic analysis of data; 'PrEP service aspects, settings and staff'; 'PrEP prescriber experiences, therapeutic alliance and care planning'; 'PrEP adherence within formal service structures'; and 'Multi-disciplinary and innovative PrEP care pathways'. The review highlights the complexities in providing optimal PrEP services for MSM by mapping and illustrating the importance of understanding the informal and formal routes to PrEP use among this HIV risk population; the barriers to uptake; the requirement for the presence of a positive therapeutic alliance between patient and prescriber in supporting patient initiation and adherence to PrEP regimes; and the need for availability in different culturally and ethnically sensitive models of PrEP service delivery according to low to high risk groups within the MSM communities.

Pre-exposure prophylaxis during the SARS-CoV-2 pandemic: can PrEP prevent COVID-19-related symptoms?

It has been speculated that some drugs can be used against SARS-CoV-2. As for antiretrovirals, the follow-up of pre-exposure prophylaxis (PrEP) users during the coronavirus disease 2019 (COVID-19) outbreak may help to understand the potential protective effect of PrEP against SARS-CoV-2. We aimed to identify associations between oral PrEP use and COVID-19-related symptoms self-reporting. Phone call interviews or digital investigation (through WhatsApp^® or e-mail) about oral PrEP regular use, social distancing, exposure to suspected or confirmed cases of SARS-CoV-2 infection and COVID-19-related symptoms. Among 108 individuals, the majority were cisgender, white and gay men. Although most of the individuals engaged in social distancing (68.52%), they kept on taking PrEP (75.93%). Few people have had contact with suspected or confirmed cases of COVID-19 (12.04%), but some had COVID-19-related symptoms the month before the interview (27.78%) including rhinorrheoa (56.67%), cough (53.33%), asthaenia (50.00%) and headache (43.33%). Also, oral PrEP was associated with lower self-reporting COVID-19-symptoms (OR 0.26, 95% CI 0.07–0.96, P = 0.04; h = 0.92) even after controlling confounders as social distancing, age, body-mass index and morbidities . In our sample, the regular use of oral PrEP was associated with lower self-reporting of COVID-19-related symptoms during the outbreak in São Paulo, Brazil.

Acceptability of Long-Acting Injectable Cabotegravir (CAB LA) in HIV-Uninfected Individuals: HPTN 077

Long-acting injectable PrEP could offer an alternative to daily oral PrEP, improve adherence and protection, if found acceptable, safe and effective. HPTN 077 evaluated injectable cabotegravir safety, tolerability and pharmacokinetics among HIV-uninfected males and females in sequentially-enrolled cohorts of two dosing strategies. We compared acceptability of product attributes, prevention preferences and future interest in injectable PrEP (FIIP) by region, sex-at-birth, arm and cohort and used multivariable analysis to identify FIIP determinants. Baseline injectable PrEP preferences were higher in non-U.S. sites and increased in both regions over time. In multivariable models, FIIP was most strongly associated with acceptability of product attributes, was higher in non-U.S. sites and more altruistic participants. Treatment arm and report of pain were not associated with FIIP. Injectable acceptability was highest in non-U.S. sites. Preferences for injectable versus other PrEP methods were higher among U.S. males than females, but higher among males and females in non-U.S. settings.

Beliefs Associated with Intention to Use PrEP Among Cisgender U.S. Women at Elevated HIV Risk

Women comprise 19% of those newly diagnosed with HIV in the U.S. There is a wide gap between recommended use of pre-exposure prophylaxis (PrEP) and actual uptake among women who are eligible for PrEP. In order to identify women's beliefs and intentions about starting PrEP, a survey, informed by the reasoned action approach, was administered to 160 cisgender PrEP-eligible women, age 18-55, in Philadelphia and New York City. The mean age was 40.2 years (SD = 11.78), 44% had completed high school, 75% were unemployed, and 85% experienced financial instability in the past 3 months. Multivariate linear regression analyses identified sets of behavioral and normative beliefs associated with intention to start PrEP in the next 3 months. Behavioral beliefs reflected views about PrEP benefits such as preventing HIV, and normative beliefs reflected perceptions of support or lack thereof from others including partners, friends, mother, and children. These findings can be used to inform interventions to foster greater PrEP uptake among women.

Predicting Pharmacokinetics of a Tenofovir Alafenamide Subcutaneous Implant Using Physiologically Based Pharmacokinetic Modelling

Long-acting (LA) administration using a subcutaneous (s.c.) implant presents opportunities to simplify administration of antiretroviral drugs, improve pharmacological profiles, and overcome suboptimal adherence associated with daily oral formulations. Tenofovir alafenamide (TAF) is a highly potent nucleoside reverse transcriptase inhibitor (NRTI) and an attractive agent for LA delivery, with a high potency and long intracellular half-life. The aim of this study was to predict minimum TAF doses required to achieve concentrations effective for HIV preexposure prophylaxis (PrEP). Daily drug release requirements were then ascertained by averaging across the dosing interval. A TAF physiologically based pharmacokinetic (PBPK) model was developed and partially qualified against available oral single- and multiple-dose pharmacokinetics. The models were assumed to be qualified when simulated values were within 2-fold of the observed mean. TAF s.c. implants were simulated in five hundred individuals, reporting predicted TAF plasma and tenofovir (TFV) plasma concentrations for various release rates. Intracellular TFV diphosphate (TFV-DP) concentrations were also simulated in peripheral blood cells and cervical and rectal tissues. The minimum dose predicted to achieve intracellular TFV-DP levels above a target concentration of 48 fmol/10⁶ cells for a month was identified. TAF, TFV, and TFV-DP concentrations for release rates between 1.0 and 1.6 mg/day were simulated. The PBPK model indicated that a minimum release of 1.4 mg/day TAF is necessary to achieve TFV-DP concentrations above the identified target in peripheral blood mononuclear cells (PBMCs). TFV-DP cervical and rectal tissue concentrations were predicted to be between 1.5 and 2.0 fmol/10⁶ cells and 0.9 and 1.1 fmol/10⁶ cells, respectively, for release rates between 1.3 and 1.6 mg/day. These simulations provide target minimum doses for LA TAF PrEP in humans. Based on the generated results, multiple implants delivering a total of 1.4 mg/day of TAF subcutaneously could provide protection levels for approximately 6 months to 1 year. This modeling may inform future design of s.c. implants to mitigate adherence issues for effective PrEP applications.

Safety and tolerability of injectable Rilpivirine LA in HPTN 076: A phase 2 HIV pre-exposure prophylaxis study in women

BACKGROUND

Daily oral TDF/FTC is protective against HIV infection when used for pre-exposure prophylaxis (PrEP). However, daily adherence to oral PrEP is difficult for many; therefore, finding alternative PrEP strategies remains a priority. HPTN 076 evaluated the long-acting injectable form of rilpivirine (RPV), known as RPV LA for safety, pharmacokinetics and acceptability.

METHODS

HPTN 076 (NTC 02165202) was a phase 2, double-blind, 2:1 randomized trial comparing the safety of 1200mg RPV LA (LA) to placebo (P). The study included a 28-day oral run-in phase of daily, self- administered oral RPV (25 mg), with directly observed oral dosing about six times. Of 136 enrolled sexually active, HIV-uninfected, low HIV-risk African (100) and US (36) adult women, injectable product was administered in two gluteal, intramuscular (IM) injections once every eight weeks to 122 participants following the oral run-in phase. A maximum of six injection time points occurred over a 48-week period. Acceptability, safety, tolerability and pharmacokinetic (PK) data were collected throughout the study. This paper includes primary endpoint data collected up to the week 52 post enrollment.

FINDINGS

The median age of the enrolled population was 31 years (IQR: 25,38), median weight 75 kg (IQR: 64, 89), median body mass index (BMI) 30 (IQR: 27, 35), 46% married, 94% Black and 60% unemployed. A total of 122 (80 LA, 42 P) women received at least one injection and 98 (64 LA, 34 P) received all six injections. During the injection phase, three women withdrew from the study (2 LA, 1 P) and 16 women discontinued study product (10 LA, 6 P). Fourteen women (11 LA and 3 P) discontinued oral study product and did not enter the injection phase. Study product discontinuations were not significantly different between the two arms throughout. Of the product discontinuations in the injection phase, 8% in LA and 5% in P arm were due to adverse events (AEs), including one randomized to the P arm with prolonged QTc interval on EKG. The proportion of women who experienced Grade 2 or higher AEs during the injection phase as the primary outcome was not significantly different between the two arms [73.8%, 95% CI: (63.2%, 82.1%) for LA and 73.8%, 95% CI: (58.9%, 84.7%), p>0.99]. Transient Grade ≥2 liver abnormalities occurred in 14% of women in the LA arm compared with 12% in P arm. Three LA women (4%) developed Grade 3 injection site reactions compared with none in P arm. In participants who received at least 1 injection, the geometric mean of overall RPV trough concentrations (Ctrough) was 62.2 ng/mL. In participants who received all six injections, the geometric mean of CTrough through the injection phase and after the last injection were 72.8 ng/mL and 100.9 ng/mL, respectively. At week 52 (eight weeks after last injection), the geometric mean of RPV Ctrough was 75.0 ng/mL. At the last injection visit (Week 44), 80 % of women who answered acceptability questions strongly agreed that they would think about using- and 68% that they would definitely use a PrEP injectable in the future.

INTERPRETATION

RPV LA IM injections every eight weeks in African and US women were safe and acceptable. Overall, despite more injection site reactions and pain in the participants receiving RPV LA the injections were well tolerated. Data from this study support the further development of injectable PrEP agents.

Scaling up pre-exposure prophylaxis in sub-Saharan Africa

PURPOSE OF REVIEW

Pre-exposure prophylaxis (PrEP) is highly efficacious for preventing HIV. Demonstrations worldwide show growing acceptability with nonoral formulations in the pipeline. Despite these successes, oral PrEP scale-up in sub-Saharan Africa (SSA), the region hardest hit by HIV, remains sub-optimal. This review details emerging practises and addresses challenges in PrEP scale-up and delivery within SSA.

RECENT FINDINGS

PrEP scale-up varies across SSA. Some countries face implementation challenges, whereas most have not applied for or received regulatory approval. As governments balance treatment and prevention costs, PrEP advocacy is growing. Demand has been slow, because of low-risk perception, HIV treatment conflation or poor information. Challenges in SSA are markedly different than elsewhere, as delivery is targeted to generalized heterosexuals, rather than only key populations. SSA requires public sector engagement and innovative delivery platforms.

SUMMARY

PrEP scale-up in SSA is sub-optimal, hindered by regulatory processes, implementation challenges, poor community engagement and inadequate funding. Approaches that acknowledge overburdened, under-resourced health sectors, and seek opportunities to integrate, task-shift, decentralize and even de-medicalize, with a tailored approach, while campaigning to educate and stimulate demand are most likely to work. Solutions to oral PrEP scale-up will apply to other formulations, opening new avenues for ARV (microbicides and injectables) and non-ARV-based (future vaccine) biomedical prevention provision.

A Meta-analysis of Passive Immunization Studies Shows that Serum-Neutralizing Antibody Titer Associates with Protection against SHIV Challenge

Passively administered broadly neutralizing antibodies (bNAbs) targeting the HIV-1 envelope glycoprotein (Env) have been shown to protect non-human primates (NHPs) against chimeric simian-human immunodeficiency virus (SHIV) infection. With data from multiple non-human primate SHIV challenge studies that used single bNAbs, we conducted a meta-analysis to examine the relationship between predicted serum 50% neutralization titer (ID50) against the challenge virus and infection outcome. In a logistic model that adjusts for bNAb epitopes and challenge viruses, serum ID50 had a highly significant effect on infection risk (p < 0.001). The estimated ID50 to achieve 50%, 75%, and 95% protection was 91 (95% confidence interval [CI]: 55, 153), 219 (117, 410), and 685 (319, 1471), respectively. This analysis indicates that serum neutralizing titer against the relevant virus is a key parameter of protection and that protection from acquisition by a single bNAb might require substantial levels of neutralization at the time of exposure.

The role of costing in the introduction and scale-up of HIV pre-exposure prophylaxis: evidence from integrating PrEP into routine maternal and child health and family planning clinics in western Kenya

INTRODUCTION

Understanding the cost of strategies to reach and deliver pre-exposure prophylaxis (PrEP) to priority populations is essential to assess the cost-effectiveness and budget impact of HIV prevention programmes. Providing PrEP through maternal and child health and family planning clinics offers a promising strategy to reach women in high HIV burden settings. We estimated incremental costs and explored the cost drivers of integrating PrEP delivery into routine maternal and child health and family planning services in Kenya.

METHODS

We conducted a costing study from the provider perspective within the PrEP Implementation for Young Women and Adolescents programme in western Kenya. We identified all within- and above-facility activities supporting PrEP delivery and measured clinical service time using time-and-motion studies. We obtained input costs from programme budgets, expenditure records and staff interviews. We estimated changes in costs if creatinine testing were postponed from initiation to first follow-up visit and if PrEP were prioritized to clients at high HIV risk using a behavioural risk assessment tool. We also projected costs under Ministry of Health (MOH) implementation assuming MOH salaries and programme supervision. We estimated annual numbers of PrEP visits from programme data abstracted from 16 facilities between November 2017 and June 2018. We report the cost per client-month of PrEP dispensed in 2017 USD.

RESULTS

For an annual programme output of 24,005 screenings, 4198 PrEP initiations and 4427 follow-up visits, the average cost per client-month of PrEP dispensed in the study was $26.52. Personnel, drugs and laboratory tests comprised 43%, 25% and 14% of programme costs respectively. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk reduced total programme costs by 8% and 14% respectively. In the MOH scenario assuming no changes in outputs, the projected cost per client-month of PrEP dispensed decreased to $16.54 and total programme costs decreased by 38%.

CONCLUSIONS

Incremental PrEP costs are sensitive to the service delivery strategy used to engage priority populations. Postponing creatinine testing and prioritizing PrEP delivery to clients at high HIV risk may reduce costs. Context-specific cost data are crucial to assess the cost-effectiveness and affordability of PrEP delivery models.

Next-Wave HIV Pre-Exposure Prophylaxis Implementation for Gay and Bisexual Men

Data indicate that diffusion of pre-exposure prophylaxis (PrEP) programs for HIV prevention is increasing in the United States; however, persistent disparities in PrEP access remain. Earlier waves of PrEP implementation focused on development (2012-2015) and diffusion (2016-2018). To reduce disparities, the next wave of PrEP implementation should focus on integration; that is, the assimilation of PrEP service as an integral part of HIV prevention, sexual health, and primary care. This review analyzes PrEP implementation literature in the context of three "next-wave" challenges: increasing patient demand, enhancing provider investment and competency, and improving health systems capacity. Our review revealed five activities we consider critical to successful next-wave PrEP implementation efforts: (1) redefining PrEP eligibility assessment, (2) de-emphasizing risk perception as a strategy to increase demand, (3) rejecting risk compensation arguments, (4) altering guidelines to make PrEP follow-up less onerous, and (5) focusing directly on strategies to reduce the cost of PrEP medication. This article ends with a case study of a research-practice partnership designed to instantiate new approaches to integrative implementation efforts.

The impact of market segmentation and social marketing on uptake of preventive programmes: the example of voluntary medical male circumcision. A literature review

Background: The business world has long recognized the power of defining discrete audiences within a target population. However, market segmentation's full potential has not been applied to the public health context. While some broad elements of market segmentation (e.g., age, geography) are considered, a nuanced look at behavioural and psychographic segmentation, which could greatly enhance the possibility of lasting behaviour change, is often missing.   Segmentation, and the associated mindset which acknowledges the multi-dimensional differences between people, allows service providers, implementers, policymakers, and government officials to target initiatives and lead to a greater likelihood of lasting behavioural change. This paper investigates what segmentation is, how it has been applied to voluntary medical male circumcision (VMMC), how it can be applied in development, and the challenges in both measuring and adopting segmentation as part of program design. Methods: We performed a detailed search of peer-reviewed literature using PubMed, ProQuest, ScienceDirect, Google Scholar, and the abstract directories of the International AIDS Society (IAS) published between January 2015 and September 2018. We also accessed articles from business databases such as the Harvard Business Review.   Results: Results from a VMMC-focused intervention that successfully designed and delivered segmentation-based programs in two countries demonstrated that it is possible to adapt private sector approaches. However, within the sector of global development that is most familiar with segmentation, these efforts rarely go beyond basic demographic segments. Conclusions: Existing published material tends not to measure the impact of segmentation itself, but the impact of the intervention to which segmentation was applied, which makes it challenging for the development sector to invest in the approach without evidence that it works. Nonetheless, the experiences of segmentation and demand creation for VMMC do highlight the opportunity for better integrating this approach in HIV prevention and in global development and measurement initiatives.

Neutralization and beyond: Antibodies and HIV-1 acquisition

It is widely accepted that an effective HIV-1 preventative vaccine must elicit antibodies that can block virus acquisition. Although, anti-HIV-1 broadly neutralizing antibodies (bnAbs) have been isolated, unfortunately, no vaccine immunogens have been designed that can elicit these bnAbs in uninfected at-risk individuals. Some studies have suggested that other antibody functionalities, besides neutralization, such as antibody-dependent cellular cytotoxicity (ADCC), may prevent HIV-1 acquisition. In contrast to bnAbs, ADCC-inducing antibodies may be more amenable to elicitation by current vaccine technologies. This review will provide clarity about the role of nAbs and ADCC-inducing antibodies in preventing transmission, highlight mechanisms that potentially explain how ADCC-mediating antibodies may work, and speculate about the generation of these novel protective antibodies. Anti-HIV-1 ADCC-inducing antibodies may provide a new avenue for developing an effective HIV-1 vaccine.